Cardiology cathlab-based management of thrombotic carotid stenoses in acute ischaemic stroke: tools, techniques, local stroke unit collaboration, challenges and patient outcomes

Background

Shortage of endovascular operators able to deliver thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis) in managing stroke mechanistic pathologies such as AFib (pharmacology/ablation) or PFO (diagnosis/closure).

Purpose

To present accumulating experience en route to a full interventional stroke service on the basis of a cardiac cathlab and local multi-specialty collaboration.

Methods

Withn the PARADIGM-EXTEND (symptomatic and increased-stroke-risk asymptomatic carotid stenosis) all-comer study we have treated, on an emergent basis, 21 patients (15 men, age 58–83 years, median 68 years) with AIS caused by severe carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service.

Results

All lesions (100%) were thrombotic (mobile thrombus - 29%; one was a thrombotic total occusion). Proximal neuroprotection (flow reversal using a CCA±ECA balloon) with thrombus aspiration was used in 19/21 patients (90.5%; in ICA total thrombotic occlusion TigerTrieverXL was used). In 2 patients proximal system use was unfeasible. All cases were done under ACT control and using, consistent with the PARADIGM-EXTEND protocol, the MicroNET-covered embolic prevention stent system (CGuard) that was routinely optimized with large balloons/high pressures.

There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases. Embolism-to-infarct territory was 0% and embolism-to-new territory was 0%. Vascular access closure device use was 76%. A 30-day good clinical outcome (mRS of 0–2) rate was 95.2%. One patient with thrombotic near-occlusion, in whom crescendo stroke episodes superimposing the baseline late presentation event necessitated treatment, had a haemorrhagic stroke transformation on day 2 that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred.

Conclusion

Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for AMI have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS. Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy. Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services, including thrombectomy, in the cardiology cathlab.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): John Paul II Hospital in Krakow and Jagiellonian University

Relationship between left ventricular global longitudinal strain, infarct size and left ventricular function in patients with acute myocardial infarction in a stem cell therapy study

Introduction

It is critically important to determine the accuracy, and relationships between, non-invasive imaging modalities, such as two-dimensional echocardiography (TTE), gated single-photon emission computed tomography (SPECT) and cardiac magnetic resonance imaging (cMRI) in patients with recent acute myocardial infarction (AMI) because these are used as clinical trial endpoints. Modest improvements in the left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and infarct zone size (IS) have been reported in AMI stem cells therapy trials (SCT).

Purpose

The aim of the study was to evaluate left-ventricular global longitudinal strain (GLS) in patients with AMI enrolled to SCT and assess its relation with infarct zone, LVEF and LVEDV using multimodality imaging including TTE, cMRI and SPECT.

Methods

Twenty-eight patients (21 male, 7 female, mean age 60.0±8.7 years) with first AMI, 2–5 days after left anterior descending percutaneous coronary intervention (PCI) and IS ≥10% were enrolled. GLS was evaluated with two-dimensional speckle tracking echocardiography (aCMQ, Philips Epiq 7). Infarct zone was measured using SPECT (E.CAM, Siemens) and gadolinium-enhanced cMRI (Siemens Magnetom Sonata 1.5T). LVEF and LVEDV were assessed with TTE (Auto-ROI, Philips), SPECT (GSQUAN, Siemens) and cMRI (MASS Medis). Measurements were obtained independently by blinded analysts.

Results

Mean GLS was −11.0±2.5% and showed a positive correlation with infarct zone by SPECT and MRI, negative with TTE-LVEF and cMRI-LVEF (Figure 1) and borderline with SPECT-LVEF (r=−0.35, p=0.08). There was no correlation between GLS and TTE-LVEDV (r=−0.25, p=0.25); SPECT-LVEDV (r=−0.38, p=0.077) and MRI-LVEDV (r=−0.20, p=0.365).

Patients in the third and fourth GLS quartile had a smaller IS measured by MRI and a trend toward a smaller infarct zone by SPECT (table 1). Patients in the GLS fourth quartile had higher TTE-LVEF and a trend toward higher cMRI-LVEF compared with other quartiles.

LVEF measured with TTE and cMRI was higher compared with SPECT-LVEF (+2.6±6.8%, p=0.006 and +4.2±7.8%, p=0.030, respectively) with no difference between TTE-LVEF and MRI-LVEF (p=0.823) (Table 1).

LVEDV evaluated by SPECT and MRI was higher compared with TTE-LVEDV (+48.3±24.9 ml, +47.7±29.5 ml, both p<0.001) with no difference between SPECT-LVEDV and MRI-LVEDV (p=0.984)

Conclusions

In patients with anterior wall AMI, 2–5 days after PCI, GLS showed a good correlation with infarct zone quantified by SPECT and MRI and with LVEF measured with TTE and cMRI. GLS might thus be a valuable tool in the evaluation of myocardial injury in SCT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland/ZDS/00564 Jagiellonian University Medical College Table 1Figure 1

Prevalence of cardiac amyloidosis in patients with unexplained left ventricle hypertrophy

Background

Amyloid cardiomyopathy (CA) it is more frequently diagnosed due to rapidly developing imaging modalities. Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired wild-type (ATTRwt) and hereditary (ATTRm). Types of TTR gene variants display genetic and ethnic variability. The aim of this prospective study was to assess the prevalence and types of pathogenic genetic variants associated with ATTRm amyloidosis in patients with unexplained left ventricle (LV) hypertrophy.

Methods

We evaluated prospectively 101 consecutive patients (37 (37%) females, age: 69.7±13.6 y.o.) in years 2016–2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE), single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), and in selected cases cardiac or soft tissue biopsy. Patients with DPD cardiac uptake in SPECT or positive histopathology or family history of ATTR were subjected to genetic testing by an amplicon-based next-generation TTR sequencing approach.

Results

Enrolled patients presented with marked LV hypertrophy with maximum wall thickness of 18.9±4 mm. Based on performed tests 34 patients (33.7%) were diagnosed with amyloidosis, including 17 cases of light-chain amyloidosis (AL), 16 of ATTR, and 1 case of other type of amyloidosis. Overall, patients with CA presented with mean 2.6±0.9 NYHA class. In TTE there was LV maximum wall thickness of 19.5±4 mm and LV mass value index value of 182±48 g/m2, decreased global longitudinal strain value (GLS, −14.1±5%) and advanced diastolic dysfunction (EA 2.2±1.1, E/E' 22±9). Overall, there were 8 cases of ATTRwt and eight patients were diagnosed ATTRm. There were detected following types of TTR variants - c.302C>T p.(Ala101Val) in a single male patient, c.325G>A p.(Glu109Lys) in a single male patient and c.157T>C p.(Phe53Leu) in six patients. Overall, 10 patients with ATTR presented with polyneuropathy, additionally six had diagnosed carpal tunnel syndrome. All patients with ATTRm had positive family history for CA.

Conclusions

In patients with unexpected LV hypertrophy evaluated in a cardiology referral center a high number of patients may suffer from underlying CA. Types of detected TTR gene variants associated with CA included most often Phe53Leu, and rare variants Ala101Val, Glu109Lys.

Funding Acknowledgement

Type of funding sources: None.

Scintigraphic and echocardiographic evaluation of patients with cardiac transthyretin amyloidosis and first-degree relatives

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Pfizer Research Grant (ID#57165999)

Background

Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired or wild-type (ATTRwt) and hereditary (ATTRm), which is transmitted in an autosomal dominant inheritance with a variable penetrance.  Types of transthyretin (TTR) gene mutations display genetic and ethnic variability.

Purpose

The aim of this prospective study was to assess the TTR gene variants, echocardiographic parameters and regional left ventricle 99mTc-DPD uptake among patients with ATTR and first-degree relatives.

Methods

We present data based on evaluation of first 25 patients (13 (52%) females), including 10 (40%) index patients with ATTR (age 66.4 ± 13 years) and 15 (60%) first-degree relatives who were studied between June 2020 and February 2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE) with global longitudinal strain (GLS) analysis, single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), genetic testing by an amplicon-based next-generation TTR sequencing approach, and in selected cases cardiac or soft tissue biopsy.

Results

Overall, 6 index patients were diagnosed with ATTRm and 4 with ATTRwt presenting mixed, cardiac or neuropathic phenotype. There were detected following types of TTR variants - Phe53Leu, Ala101Val, Glu112Lys, Glu109Lys. Nine out of 10 index patients were diagnosed with amyloid cardiomyopathy (CA) with grade 2-3 tracer uptake in SPECT and symptomatic heart failure (NYHA 2.2 ± 1.1; NT-proBNP value 2224 ± 2799 pg/ml). In both ATTRm and ATTRwt there were patients presenting with either focal or diffuse tracer pattern evaluated by SPECT technique. In TTE there was marked left ventricle (LV) hypertrophy with maximum wall thickness of 22 ± 5 mm and LV mass value index value of 382 ± 111 g/m2. All patients with CA had abnormal global longitudinal strain (GLS, -14.5 ± 5%) and diastolic dysfunction (EA 1.56 ± 0.76, E/E’ 16 ± 11). None of relatives expressed tracer uptake in scintigraphy. Overall, 5 first-degree relatives were diagnosed with Phe53Leu variant, among them two patients presented with decreased GLS value.

Conclusions

Patients with ATTR presented in TTE with LV hypertrophy, decreased GLS value, diastolic dysfunction and grade 2-3 in scintigraphy with either focal or diffuse tracer uptake in SPECT technique. None of first-degree relatives expressed increased tracer uptake in scintigraphy. However, some of relatives who were diagnosed with pathogenic TTR variant presented with decreased GLS value.

Temporal changes in the implementation of secondary prevention of coronary artery disease in every day practice

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

-

Introduction

Patients with coronary artery disease (CAD) are at high risk of recurrent cardiovascular events and control of their risk factors is crucial.

Objectives

Comparison of risk factors control in patients with CAD in 2016–2017 and 2011–2013.

Patients and methods

Five hospitals with cardiology departments serving the city and surrounding districts participated in the study. Consecutive patients hospitalized due to an acute coronary syndrome or a myocardial revascularization procedure were interviewed 6–18 months after hospitalization. The surveys were carried out in 2011–2013 and 2016–2017.

Results

We examined 616 patients in 2011–2013 and 388 in 2016–2017 (mean age: 64.7 ± 8.8 vs. 66.4 ± 8.4, P <0.01). After adjusting for covariates the proportion of patients with high blood pressure decreased by 8.9% (95% confidence intervals: -2.1% – -15.6%) and proportion of patients with high LDL cholesterol decreased by 9.5% (-2.2% – -16.7%) in 2016/2017 compared to 2011/2013, whereas the proportion of smoking patients (-0.2% [-6.0% – 5.5%]) and those with high glucose level (3.9% [-2.2% - 10.0%]) and with body mass index ≥25 kg/m2 (3.8% [-3.9% – 11.6%]) did not change significantly. The proportion of patients prescribed antiplatelets (6.5% [2.6% - 10.3%]), β-blockers (7.4% [2.2% - 12.6%]), angiotensin converting enzyme inhibitors or sartans (8.6% [2.9% – 14.3%]), calcium antagonists (8.1% [1.3 – 15.0]) and anticoagulants (5.5% [0.7% - 10.2%]) increased significantly.

Conclusions

In CAD patients, there was an increase of the proportion of patients with cardiovascular drugs prescribed and a slight improvement in the control of blood pressure and LDL cholesterol between 2011–2013 and 2016–2017. However, no significant changes were found for the other main risk factors.

Patients who do not reach treatment goal Survey Smoking, % BP not at goal, %a BP ≥140/90 mmHg, % LDL cholesterol ≥1.8 mmol/l, % HbA1c ≥7.0%b, % Fasting glucose ≥7.0 mmol/l, % BMI≥25 kg/m2, % BMI≥30 kg/m2, % 2011-2013 19.0 50.3 43.0 71.9 14.1 15.9 81.2 33.8 2016-2017 16.2 40.7 39.2 60.3 14.9 20.2 83.4 38.3 P value 0.26 <0.01 0.24 <0.001 0.76 0.09 0.37 0.14 Differences adjusted for age, sex, index diagnosis, duration of education, professional activity (95% confidence intervals) 2016-2017 vs 2011-2013 -0.2(-6.0 - 5.5) -8.9(-15.6 - -2.1) -6.7(-14.3 - 1.0) -9.5(-16.7 - -2.2) 2.0(-3.4 - 7.4) 3.9(-2.2 - 10.0) 3.8(-3.9 - 11.6) 1.6 (-5.8 - 9.0) Abbreviations BMI, body mass index; BP, blood pressure; LDL, low-density lipoprotein a BP goal of <140/90mmHg (<130/80 mmHg in diabetics) in 2011–2013 and <140/90 mmHg (<140/85 mmHg in diabetics) in 2016–2017 b available for 362 patients in 2011-2013 and 383 patients in 2016-2017

Prognostic accuracy of common heart failure scales in patients with dilated cardiomyopathy

Introduction

The reliable identification of patients with heart failure (HF) and high mortality risk is crucial for treatment optimalization and prognostication, especially in younger population in dilated cardiomyopathy (DCM). However, the profile of DCM patients significantly differs from the general HF population. Therefore, the applicability of commonly used HF prognostic scales may be sub-optimal in DCM.

Purpose

Comparison of the prognostic accuracy of common HF prognostic scales in DCM.

Methods

Between 2010 and 2018 we analysed 406 DCM in- and outpatients (aged 54±14 years, 76% male, NYHA: 2.5±0.9, symptoms duration: 40±58 months, EF: 26±9%, LVEDd: 66±10mm, NT-proBNP: 3662±7617pg/ml, 10% had ICD, 3.5% had CRT). The mortality risk was assessed by 8 most popular HF prognostic scores. In 2019 information on patients status were gathered after 48±32months.

Results

During first month 4 patients (1.0%) died, after 1 year – 19 (6%), 2 years – 32 (11%), 3 years – 42 (18%), 4 years – 52 (27%), 5 years – 59 (40%). BCN and SHFM calculators had the best prognostic ability for 1–5 years mortality (Table 1).

Conclusions

Mortality risk of DCM patients during 5 years is high and reaches 40%. BCN and SHFM calculators had the best prognostic ability for 1–5 years mortality.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Department of Scientific Research and Structural Funds of Medical College, Jagiellonian University

Angiographic SYNTAX score reduction in de novo left main coronary stenosis patients over the last decade: implications for revascularization approach

Introduction

Percutaneous management of left main (LM) coronary artery stenosis is an acceptable alternative to surgery in selected group of patients.

Purpose

To investigate potential angiographic trends in de novo LM coronary artery stenosis patients. Those may impact revascularization mode but remain undetermined.

Methods

Clinical records and all consecutive coronary angiograms in our Institution from 1st January 2010 to 31stDecember 2019 were evaluated to identify those with newly diagnosed angiography-significant (≥50% lumen diameter reduction) LM stenosis. Angiographic SYNTAX score (SS) assessment was performed by agreement of two experienced analysts (an angiographic core lab analyst and a Heart Team interventional cardiologist) on anonymized angiograms. Values of the overall SS, SS of the LM lesion and SS beyond LM were determined according to SS assessment methodology. Pearson's correlation and Fisher transformation were used to evaluate parametric variables. Spearman's rho was used to determine trends.

Results

Overall, out of 12315 coronary angiographies performed in de novo referrals in the last decade, 357 (2.90%) showed significant left main stenosis; the proportion varied from 2.30% to 3.48% annually. Patient mean age was 68.8 years (23.3% women). No temporal trends in patient age or gender occurred over the last decade while the overall SS deceased from a mean value of 35 to 28 (SC=−0.16, p=0.003). Further analysis showed a particular negative trend in the non-LM-SS (SC=−0.17, p=0.001) but not in the LM-SS (SC=0.04, p=0.47). No temporal trend was present is the prevalence of isolated LM stenosis (p=0.48) and no temporal trend in the LM stenosis angiographic severity (<70% vs. ≥70%; p=0.61), LM stenosis location (ostial/mid/bifurcation/entire left main; p=0.30) nor in the number of LM segments affected (SC=0.05, p=0.30). Reduction in the non-LM-SS was associated with a decrease in the number of coronary arteries with a significant angiographic atherosclerotic involvement (SC=−0.12, p=0.03) and in the number of coexisting total occlusions (SC=−0.25, p<0.001).

Conclusion(s)

(1) In patients with newly diagnosed LM critical stenosis overall angiographic SS showed a statistically significant negative trend over last decade, with a reduction from mean 35 (2010) to 28 points (2019); a finding that may be related to a change in the angiographic presentation of the disease or an earlier identification of LM stenosis patients over time. (2) The overall SS reduction was driven by a decrease in non-LM-SS. This, taken together with the overall SS reduction from above 32 to below 32, favours (as per current guidelines) the endovascular approach to left main revascularization. Our findings suggest an increase in the proportion of LM stenosis patients with angiography feasible to percutaneous intervention.

SYNTAX score trends over the last decade

Funding Acknowledgement

Type of funding source: None

Evolution of left ventricular function after Wharton's jelly mesenchymal stem cells transcoronary administration: 5-year follow up in a pilot cohort of CIRCULATE-AMI Randomized Trial

Introduction

CIRCULATE-Acute Myocardial Infarction is a double-blind controlled trial randomizing (RCT) in 105 consecutive patients with their first, large AMI (cMRI-LVEF ≤45% and/or cMRI-infarct size ≥10% of LV) with successful infarct-related artery (IRA) primary percutaneous coronary intervention (pPCI) to transcoronary administration of Wharton's Jelly Mesenchymal Stem Cells (WJMSCs) vs. placebo (2:1). The pilot study cohort (PSC) preceded the RCT.

Aim

To evaluate WJMSCs long-term safety, and evolution of left-ventricular (LV) function in CIRCULATE-AMI PSC.

Material and methods

30 000 000 WJMSCs (50% labelled with 99mTc-exametazime) were administered via IRA in a ten-patient PCS (age 32–65 years, peak hs-Troponin T 17.3±9.1ng/mL and peak CK-MB 533±89U/L, cMRI-LVEF 40.3±2.7% and infarct size 20.1±2.8%) at ≈5–7 days after AMI using a cell delivery-dedicated, coronary-non-occlusive method. Other treatments were per guidelines.

WJMSCs showed an unprecedented high myocardial uptake (30.2±5.3%; 95% CI 26.9–33.5%), corresponding to ≈9×10 000 000 cells retention in the infarct zone – in absence of epicardial flow or myocardial perfusion impairment (TIMI-3 in all; cTFC 45±8 vs. 44±9, p=0.51) or any hs-Troponin T elevation. Five-year follow up included cardiac Magnetic Resonance Imaging (cMRI) (at baseline, 1 year and 3 years) and detailed echocardiography (echo) at baseline, 1 year, 3 years and 5 years.

Results

By 5 years, one patient died from a new, non-index territory AMI. There were no other cardiovascular events and MACCE that might be related to WJMSCs transplantation.

On echo (Fig), there was an increase in left ventricular ejection fraction (LVEF) between WJMSCs administration point and 1 year (37.7±2.9% vs. 48.3±2.5%, p=0.002) that was sustained at 3 years (47.2±2.6%, p=0.005 vs. baseline) and at 5 years: (44.7±3.2%, p=0.039 vs. baseline). LVEF reached a peak at 1 year after the AMI and WJMSCs transfer (Fig). cMRI data (obtained up to 3 years; 1 year 41.9±2.6% vs. 51.0±3.3%, p<0.01; 3 years 52.2±4.0%, p<0.01 vs. baseline) were consistent with the echo LVEF assessment.

Conclusions

5-year follow up in CIRCULATE-AMI PSC indicates that WJMSC transcoronary application is safe and may be associated with an LVEF improvement. The magnitude of LV increase appears to peak at 1 year, suggesting a potential role for repeated WJMSCs administration(s). Currently running double-blind RCT will provide placebo-controlled insights into the WJMSCs effect(s) on changes in LV function, remodelling, scar reduction and clinical outcomes.

Echo-LVEF evolution

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland/ZDS/00564 Jagiellonian University Medical College

Cardiology cathlab-based management of thrombotic carotid stenoses in acute ischaemic stroke en route to full interventional stroke service: tools, techniques, challenges and patient outcomes

Background

Shortage of endovascular operators able to deliver manual thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in many health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis and in absence of “territorial” issues) in managing stroke mechanistic pathologies such as atrial fibrillation (pharmacology/ablation) or PFO (diagnosis/closure).

Purpose

To establish a practical path towards a clinically and orranizationally effective cardiology cathlab-based acute ischaemic stroke service, including intracranial manual thrombectomy, in a large multi-specialty hospital with a high-volume stroke unit but absence of neuroradiology service.

Methods

Withn a symptomatic and increased-stroke-risk asymptomatic carotid stenosis all-comer endovascular revascularization study (NeuroVascular Team decision-making) we have treated, on an emergent basis, 17 patients (13 men, age 58–75 years, median 67 years) with AIS caused by severe thrombotic carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service.

Results

All lesions (100%) were thrombotic (mobile thrombus - 29%). Proximal neuroprotection (flow reversal using a common carotid artery±external carotid artery occlusive balloon/s) was used in 15/17 patients (88%). In 2 patients (12%) filter protection was applied as proximal system use was unfeasible for anatomic or clinical reasons. All cases were done under activated clotting time control and using a micronet-covered embolic prevention stent system that was routinely optimized -under an effective neuroprotection- with large balloons/high pressures. There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases.

Vascular access closure device use was 76%.

A 30-day good clinical outcome (mRS of 0–2) rate was 94%. One patient had a haemorrhagic stroke transformation that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred

Conclusions

Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for acute myocardial infarction have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS.

Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy.

Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services including thrombectomy.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College

Long-term outcomes of the micronet-covered stent system routine use for carotid revsacularization in stroke prevention: PARADIGM-Extend 5 year evidence

Background

Diffusion-weighted magnetic resonance imaging indicates that micronet-covered embolic prevention stent system effectively minimizes peri-procedural and prevents lesion-related post-procedural cerebral embolism in carotid artery stenting but long-term clinical evidence is missing.

Purpose

To provide long-term clinical and duplex ultrasound evaluation of safety and efficacy of the system use in consecutive carotid revascularization patients.

Methods

PARADIGM-EXTEND is in all-comer, all-referrals-tracked study with no exclusion criteria other than lack of NeuroVascular Team-determined indication. Clinically asymptomatic patients receive revascularization only in case of increased-stroke-risk characteristics. Adverse events are independently adjudicated.

Results

Currently 451 patients (48–87 years, 59% symptomatic, 127 women) with 490 arteries crossed the first follow-up window of 30 days. There has been 100% micronet-covered embolic prevention stent system use (ie, no other stent type/s used throughout study). Proximal/distal intra-procedural neuroprotection use was 38.3%/61.7%. Large balloon/high-pressure stent optimization was routine, leading to a single-digit (mean 6.9%) residual diameter stenosis. Independent neurologist and duplex evaluation are before and after revascularization (48h and 30 days, then yearly).

Peri-procedural death or major ischemic stroke rate was 0%. One event (prior infarct scar asymptomatic extension in prolonged hypotension course) was adjudicated as minor stroke (0.22%), and there was 1 periprocedural MI (type 2, in 2-vessel non-revascularizable CTO; 0.22%).

By 30 days there were no further ischaemic strokes (0%) but there was 1 haemorrhagic transformation that led to death (0.22%) and 1 bleeding-related death (0.22%). Thus total 30-day death/stroke was 0.66%, and total death/stroke/MI was 0.88%.

By 60 months there were 3 contralateral, 1 ipsilateral (device-unrelated), and 2 posterior circulation strokes. Baseline internal carotid artery velocities were 3.72±1.25 and 0.63±0.69 m/s (peak-systolic and end-diastolic). Post-procedural in-stent velocities were normal and remained normal throughout the 60-month follow-up period: 0.78±040 and 0.21±0.10 (1y); 0.75±0.36 0.19±0.09 (2y); 0.75±0,35 and 0.21±0.09 (3y); 0.72±0.27 and 0.20±0.07 (4y); 0.79±0.58 and 0.21±0.11m/s (5y).

There were 2 in-stent restenoses by 1y (including 1 that occurred with de novo neck radiotherapy) and 1 other by 2y (total 2y in-stent restenosis of 1.1%) but no further ones (0% in-stent restenosis at 2–5y).

Conclusions

PARADIGM-Extend long-term clinical and duplex ultrasound evidence is consistent with normal healing and sustained safety and stroke prevention efficacy of the micronet-covered embolic prevention stent system used routinely, on top of optimized medical therapy, for stroke prevention in symptomatic and increased-stroke-risk asymptomatic subjects with carotid stenosis recommended for revasularization by the NeuroVascular Team.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College

The benefit of atrial septal defect closure in the elderly patients

Objective

Closure of the atrial septal defect in the elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in elderly patients.

Methods

From a total of 650 pts with ASD who underwent transcatheter closure 120 pts over 60 years (70 F, 50 M) with a mean age of 66.7±18.1 (60–78) were analyzed. All patients had an isolated secundum ASD with a mean Qp:Qs: 2.79±1.8 (1.5–3.9). A symptom-limited treadmill exercise tests with respiratory gas exchange analysis and transthoracic color Doppler echocardiographic study as well as Quality of life (QoL) measured using the SF36 questionnaire (SF36q) were repeated in all pts before procedure and after 12 months of follow-up.

Results

The device was successfully implanted in all pts (procedure time 30.1±9.9 (10–59) minutes, fluoroscopy time 10.1±7.2 (6–40) minutes). There were no major complications. The defect echo diameter was 19.5±15.4 (12 - 34) mm. The mean balloon stretched diameter of ASD was 22.0±7.8 (14 - 36) mm. The diameter of the implanted devices ranged 16 - 38 mm. After 12 months of ASD closure, all the pts showed a significant improvement of exercise capacity parameters. Seven QoL parameters (except mental health) improved at 12 months follow up compared to their baseline data. The mean SF36q scale increased significantly in 96 (80.2%) pts of mean 41.6±26.1 (4–71). The right ventricular dimension decreased in 101 pts (84.2%) (Table 1).

Conclusions

Closure of ASD in elderly patients caused a significant clinical and hemodynamic improvement after percutaneous treatment, which is maintained to long-term follow-up what justified this procedure in old age.

Funding Acknowledgement

Type of funding source: None

P1294 Distribution of infective lesions detected with radiolabeled leucocyte scintigraphy in carriers of various types of cardiac implantable electronic devices

Funding Acknowledgements

Grant from the Jagiellonian University Medical College (K/DSC/004383)

Background

The rate of cardiac device-related infective endocarditis (CDRIE) is increasing disproportionately to the rising rate of device implantations. Hybrid technique of single photon emission tomography and computed tomography with technetium99m-hexamethylpropyleneamine oxime–labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) is a developing technique in patients with suspected endocarditis.

Purpose

The aim of this study was to evaluate distribution of both intracardiac and extracardiac inflammatory lesions detected with 99mTc-HMPAO-SPECT/CT in patients with suspected CDRIE depending on the type of carried cardiac implantable electronic device (CIED).

Methods

During years 2015-2018, we prospectively enrolled 103 consecutive patients with suspected CDRIE (70 males, 61 ± 18 y.o.). Patients undergone evaluation according to current ESC guidelines and subsequently 99mTc-HMPAO-SPECT/CT. Scans were classified as positive in the presence of abnormal tracer uptake involving cardiac or/and intravascular sections of device electrodes. Patients were divided to group 1 with implanted pacemakers (61 patients) and group 2 including 42 carriers of either an implantable cardioverter-defibrillator (ICD) or a cardiac resynchronization therapy device (CRT).

Results

Overall, in group 2 there was a higher prevalence of diabetes mellitus, coronary artery disease and heart failure (p < 0.05). Moreover, group 2 had worse functional status with higher NYHA class (2.8 ± 0.9 vs. 1.7 ± 1, p = 0.001), NT-proBNP levels (5027 ± 5813 vs. 2320 ± 4279, p = 0.0004) and lower left ventricle ejection fraction (29 ± 12 vs. 54 ± 13, p = 0.0001). Both groups had comparable values of C-reactive protein, procalcitonin and white blood cells (p > 0.05). The mean time since device implantation was 3.4 ± 3.8 years and on average patients had 1.9 implanted electrodes. Patients from group 2 presented more often with 99mTc-HMPAO-SPECT/CT positive for CDRIE (45% vs. 26%, p = 0.045). Frequency of lesions consistent with infection localized within the intravascular section of the electrode and the CIED lodge did not differ between groups (p > 0.05). However, inflammatory foci in the vicinity of the intracardiac portion of the electrode were detected more often in group 2 (43% vs. 21%, p = 0.019). Overall, extracardiac inflammatory foci were found in 34% of patients, with most common localization in the gastrointestinal tract (13%) and musculoskeletal system (8%). Both prevalence and localization of extracardiac foci did not differ between groups (39% vs. 24%, p = 0.16).

Conclusions

Prevalence and localization of intracardiac inflammatory foci typical for CDRIE detected with 99mTc-HMPAO-SPECT/CT is different in patients with various types of CIEDs. Patients with implanted ICD or CRT have worse functional status and present more frequently with radiotracer uptake typical for CDRIE in 99mTc-HMPAO-SPECT/CT. Distribution of extracardiac inflammatory lesions does not differ between groups.

P967 Profile of arrhythmia in pregnant women with different WHO class is similar

Background

Arrhythmia is the most common cardiac complications during pregnancy especially in women with structural heart disease. Methods: Since January 2015 till December 2018 the consecutive 150 pregnant women with different maternal cardiovascular risk according to WHO classification: 100 in WHO I and II (gr 1);50 in WHO II-III, III, IV were enrolled. Each woman had 24-hour Holter- ECG monitoring during at least 2 trimester. Results: Except mild ventricular arrhythmia i.e ventricular extrasystole > 1000 per 24 hour, which occured more often in group1, we did not observe any significant differences in arrhythmic profile of pregnant women with different WHO risk classification (table 1). Delivery: Caesarean section was more frequent in gr 2 (86% vs 62%) but rate of stillbirths were similar among groups. Maternal death did not occurred, there was 2 (4%) foetal mortality in gr 2. Mean duration of pregnancy, children length and birthweight were significantly higher in gr 1(table1).Conclusion: Arrhythmias during pregnancy occurred particularly on the substrate of structural heart disease. According to our observation pregnant women with potentially higher risk of maternal cardiovascular events did not reveal significant arrhythmia including conduction disturbances in comparison to women in WHO class I or II.

Holter monitoring resultes Parameter Group 1; no 100 Group 2, no 50 P value Age 31(27-34) 31(28-33) 0,36 NYHA 1,34 1,32 0,76 SVE > 1000/d 2(2,15%) 2(5,88%) 0,28 VE > 1000/d 20(19,23%) 3(5,88%) 0,03 SVT 6(6,5%) 4(11,43%) 0,35 sVT 1(1%) 0 0,65 nsVT 8(8,79%) 3(8,57%) 0,96 AF/AT 0 2(4%) 0,54 AV I 5(5%) 3(6%) 0,32 AV II Mobitz I 1(1,1%) 1(2%) 0,53 AV III 0 1(2%) 0,41 Duration (weeks) 39(38-40) 37,1 0,017 Weight (grams) 3220+-641 2840+-767 g 0,02 Caesareon section 54(62%) 33(86%) 0,00 Stillbirths 22(21,57% 8(17,78%) 0,6

P1818 Baseline clinical, echocardiographic and laboratory characteristics of HFrEF patients who were started with sacubitryl+ walsartan in different clinical status: long-term stabile vs after acute heart f

Background

According to the latest approach new class ARNI with sacubitryl-valsartan may be ordered in clinically stable heart failure patients with reduced ejection fraction ( HFrEF) or short time after acute heart failure exacerbation. Methods: Since July 2016 till February 2019 we started ARNI in 50 HFrEF patients; 33 (66%) were clinically stabile during at least 3 months and 17 (34%) were short time after HF exacerbation. Results: There were no differences in age (63 vs 58) and BMI between groups. Clinically stabile patients presented significantly lower NYHA class (2 ± 0,5 vs 3 ± 0,7) and lower NT-proBNP level (1948 pg/ml vs 5570 pg/ml) in comparison to those after HF decompensation. There were no differences in left ventricular end-diastolic diameter (LVEDD), volume (LVEDV) and ejection fraction (EF) between both groups. Patients after HF decompensation had greater left and right atrium area(LAA, RAA respectively), higher estimated pulmonary artery pressure (PASP) and reduced right ventricular systolic function expressed with TAPSE (tricuspid annular plane systolic excursion) in comparison to stabile patients. Patients from both groups presented similar physical activity tolerance estimated with 6-minute walking test ( 6- MWT): 369 m vs 402 m (tbl). Conclusions: Clinical, echocardiographic and laboratory differences were observed between groups of HFrEF patients with different clinical status when ARNI was administrated.

Parameter Stabile n = 33 After HF decompensation n= 17 p- value BMI [kg/m2] 25(23-36) 25(21-26) 0,72 Age [years] 63 (39-68) 58 (42-67) 0,81 NYHA 2 ± 0,5 3 ± 0,7 0,001 NT-proBNP [pg/ml] 1948(601-2933) 5570(4147-8021) P< 0,001 6 MWT dystans [m] 369(327-432) 402(240-480) 0,32 FW [%] 23 (18-28) 19(15-26) 0,17 LVEDD [mm] 69(59-76) 64(63-71) 0,32 LVEDvol [ml] 242(153-324) 225(178-235) 0,29 TAPSE [mm] 19(14-21) 14(13-16) 0,02 LAA [cm2] 28(24-34) 36(27-39) 0,032 RAA [cm2] 19(16-30) 26(23-32) 0,046 PASP [mmHg] 31(23-43) 43(38-55) 0,046

P4679Changes in systemic inflammation and endothelial dysfunction after balloon pulmonary angioplasty

Introduction

Pulmonary endarterectomy leads to a decrease in systemic inflammation and improvement in endothelial function in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) improves pulmonary hemodynamics in patients with inoperable CTEPH.

Aim

To assess changes in systemic inflammation and endothelial dysfunction after a single BPA session and after completion of the treatment.

Methods

We enrolled consecutive, inoperable CTEPH patients who underwent BPA. Interleukin 6, 10 (IL-6, IL-10), and C-reactive protein (hsCRP) constituted markers of systemic inflammation. Endothelin-1 (ET-1) served as a marker of endothelial dysfunction. Serum concentration of selected markers was assessed in every patient before, 24 hours after the first BPA session and 6 months after completion of the BPA treatment. Age- and sex-matched healthy subjects served as a control group.

Results

We recruited 20 patients with inoperable CTEPH (6 males [30%]), aged 67 [61–74] years in New York Heart Association class III (n=19 [95%]) and II (n=1 [5%]). BPA treatment was completed with a median of 5 [2–8] BPA sessions per patient. Before starting the treatment CTEPH patients, as compared to controls (n=10), had raised serum level of IL-6 (3.82 [2.75 - 6.03] vs. 2.64 [0.88 - 4.75] pg/ml; p=0.04), hsCRP (2.47 [0.93 - 4.27] vs. 1.23 [0.48–3.21] ng/ml; p=0.02) and ET-1 (2.68 [2.24 - 3.64] vs. 1.47 [1.4 - 1.82] pg/ml; p=0.004). There was no difference in IL-10 level.

24 hours after a BPA session we observed an increased level of IL-6, IL-10 and hsCRP. (Tab.) 6 months after completion of the BPA treatment there was a reduced level of IL-6, hsCRP and ET-1 (Tab.)

Table 1. Changes (Δ) in serum concentration of analyzed markers 24 hours after a single BPA session and at 6-months assessment after completion of the BPA treatment (n=20) Initial Δ at 24 hours after single BPA p Δ at 6-months follow-up p ET-1 [pg/ml] 2.68 [2.24; 3.64] −0.2 [−0.5; 0.23] 0.21 −0.47 [−0.96; 0.05] 0.004 IL-6 [pg/ml] 3.82 [2.75; 6.03] 3.67 [1.41; 7.16] 0.008 −0.82 [−3.11; 0.54] 0.04 IL-10 [pg/ml] 0.53 [0.44; 0.58] 0.32 [0.21; 0.87] 0.006 −0.11 [−0.33; 0.14] 0.94 hsCRP [ng/ml] 2.47 [0.93; 4.27] 5.4 [3.96; 10.59] 0.008 −0.36 [−0.94; 0.16] 0.02 ET-1, endothelin 1; hsCRP, C-reactive protein; IL-6, interleukin 6; IL-10, interleukin 10.

Conclusions

Patients with inoperable CTEPH, as compared to healthy controls, exhibit an increased systemic inflammation and endothelial dysfunction, which both improve after completion of the BPA treatment. At short-term follow-up after single BPA session there is an increase in systemic inflammatory response.

3048PARADIGM-Extend prospective academic trial: Accumulating long-term evidence for MicroNet-covered stent safety and stroke prevention efficacy

Aims

To provide long-term clinical (incl neurologic) and duplex ultrasound (DUS) evaluation of the CGuard MicroNet-covered embolic prevention stent system (EPS) routine use to perform CAS in all-comer (no exclusion criteria) patients with symptomatic or increased-stroke-risk asymptomatic carotid stenosis recommended for revascularization by the NeuroVascular Team.

Methods and results

PARADIGM-Extend is a non-industry-funded, prospective academic study in all-referrals-tracked symptomatic and asymptomatic carotid stenosis. In asymptomatic lesions, intervention is mandated only in case of increased-stroke-risk features. There is first-line consideration to use the study device, with EPD choice according to tailored-CAS algorithm. Independent neurologist evaluation and DUS are performed before CAS, at 48h, 30 days, and then every 12 months. There is external source data verification, external angiographic corelab, and external statistical analysis. Currently 325 patients (48–87 years, 54.2% symptomatic) crossed the 1st follow-up window. There has been 100% CGuardEPS use. Angiographic DS was reduced from 84±8% to only 6.9±5% (p<0.001, “CEA-like” effect of CAS).

Peri-procedural death or major stroke rate was 0%. One event was CEC-adjudicated as minor stroke (0.3%), and there was one (type2) MI (0.3%). By 30 days there was one haemorrhagic transformation leading to death (0.3%) and one bleeding-related death (0.3%). Thus total death/major stroke/minor stroke rate at 30 days was 0.9%, and total death/major stroke/minor stroke/MI rate at 30 days was 1.2%. At 1- 12 months were no strokes or stroke-related deaths (0%). At 12–24 months there was one cerebellar stroke in an AFib patient that was confirmed on MRI imaging but no carotid-territory stroke or stroke deaths (0%). By 24 and 36 months there was one posterior circulation (cerebellal) infarct but no cerebral infarctions. Post-procedural in-stent velocities were normal and remained normal throughout the 36-month follow-up period (peak-systolic/end-diastolic velocity 0.69±0.29/0.18±0.09 m/s at 30 days, 0.82±0.47/0.22±0.13m/s at 12 months, 0.73±0.31/0.19±0.09m/s at 24months and 0.80±0.31/0.21±0.11 at 24months), indicating normal device healing.

Conclusions

PARADIGM-Extend accumulating 36-month clinical and DUS evidence is consistent with unprecedented, sustained safety and cerebral embolism prevention efficacy of the CGuard™ MicroNET-covered embolic prevention stent system used routinely for stroke prevention in symptomatic and increased-stroke-risk asymptomatic subjects with carotid stenosis.

Acknowledgement/Funding

K/ZDS/007819 Jagiellonian University Medical College

P774Transcoronary transfer of Wharton's jelly mesenchymal pluripotent stem cells in patients with chronic ischaemic heart failure shows safety and unprecedented high-grade myocardial uptake

Background

Chronic ischaemic heart failure (CIHF) remains an important health problem on the patient/family- and society level. In animal models, Wharton's jelly (umbilical cord matrix) multipotent stem cells (WJMSCs) effectively promote angiogenesis, can differentiate to cardiomyocytes, and drive functional myocardial regeneration. Effective uptake of regenerative cells in ischaemic-impaired tissue is fundamental for any therapeutic effect.

Purpose

To evaluate safety and myocardial uptake of WJMSCs transcoronary transfer in CIHF applied as a novel myocardial regeneration strategy employing allogenic yet hypo-immunogenic, off-the-shelf “unlimited” source of therapeutic cells (NCT03418233 pilot cohort).

Material and methods

In ten consecutive patients (age 62.6±2.5), with stable CIHF and no current need for revascularization (LVEF 29.3±3% by echo and 26.3±6% by SPECT; NT-proBNP 1746±329pg/mL; myocardial scar tissue 39.9±3.9% by SPECT) and patency of at least two major native coronary arteries or by-pass graft(s), the CardioCell Investigational Medical Product, based on 30x106 WJMSCs, was administered to viable yet hypokinetic segments using a novel algorithm including a dedicated catheter for transcoronary delivery of cellular therapies. The cells were labeled with 99mTc-extametazime to routinely evaluate their myocardial uptake magnitude.

Results

No symptoms or signs of novel myocardial ischaemia occurred with cell delivery and no patient showed any adverse periprocedural events. One hour after administration, myocardial WJMSCs uptake (SPECT) was 40.3±6%; see Fig for a typical raw data image. By 6 months there were no adverse events in the study cohort.

Figure 1

Conclusions

This work indicates safety and unprecedented high-grade myocardial uptake of WJMSCs in CIHF patients. Together with animal data, this provides basis for continued assessment of this strategy in an endpoint-powered randomized controlled clinical trial employing CardioCell as an “unlimited” off-the-shelf cellular therapy strategy.

Acknowledgement/Funding

K/ZDS/005644 and 265761 (National Centre for Research and Development STRATEGMED)

P3362Added value of radiolabeled leukocyte scintigraphy to cardiac device-related infective endocarditis diagnostic criteria

Background

Radiolabeled leukocyte scintigraphy – hybrid technique of single photon emission tomography and computed tomography with application of technetium99m-hexamethylpropyleneamine oxime-labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) is an emerging technique in patients with suspected cardiac device-related infective endocarditis (CDRIE).

Purpose

The aim of this prospective study was to assess 99mTc-HMPAO-SPECT/CT added value to modified Duke criteria (mDuke) in CDRIE diagnostic process.

Methods

During the period 2015–2018, we enrolled 103 consecutive patients with suspected CDRIE [70 males (68%), mean age: 61±18 years, mean left ventricle ejection fraction value: 44±17%)]. All patients underwent clinical, microbiologic, echocardiographic evaluation according to ESC guidelines and additionally 99mTc-HMPAO-SPECT/CT (370–740 MBq). Scans were classified as positive in the presence of abnormal tracer uptake involving cardiac and intravascular sections of device electrodes. In the analysis, we added positive 99mTc-HMPAO-SPECT/CT result as an additional major criterion to mDuke classification. Additionally, we compared the diagnostic value of the mDuke classification including 99mTc-HMPAO-SPECT/CT (mDuke-SPET/CT) with the original mDuke classification. The sensitivity and specificity of those two scales were compared with McNemar's test. Diagnostic accuracy was calculated based on final clinical CDRIE diagnosis, including microbiology, echocardiography and 6 month-long follow-up with subsequent outpatient visit.

Results

Overall 58% patients had pacemakers, 25% had implantable cardioverter defibrillators, 16% had resynchronization therapy and 1% had an epicardial lead. Mean time from device implantation was 3.4±3.8 years. Final CDRIE diagnosis was established in 31 (30%) patients. The most common pathogens causing CDRIE were Enterococci (39%) and Staphylococci (35%).

According to the original mDuke classification 16.5% patients had definite CDRIE, 49.5% had possible and in 34% CDRIE was excluded. Overall, 34% of 99mTc-HMPAO-SPECT/CT scans were positive for CDRIE. After reclassification, according to mDuke-SPET/CT the proportion of patients with definite CDRIE increased to 34%, whereas in 37% patients CDRIE was possible and in 29% cases CDRIE was excluded.

Overall, mDuke was characterized with 83% accuracy, 0.52 Cohen's kappa coefficient, 48% sensitivity, 97% specificity, 81% negative predictive value (NPV), 88% positive predictive value (PPV). Whereas mDuke-SPET/CT had 88% accuracy, 0.73 Cohen's kappa coefficient, 87% sensitivity, 89% specificity, 94% NPV, 77% PPV. Compared to mDuke, mDuke-SPET/CT had significantly higher sensitivity (p<0.001).

Conclusions

In patients with suspected CDRIE inclusion of positive radiolabeled leukocyte scintigraphy into modified Duke diagnostic criteria yields significantly higher sensitivity, as well as modest reduction of possible CDRIE diagnoses.

Acknowledgement/Funding

Grant from the Jagiellonian University Medical College (K/DSC/004383)

P4604Insights into left ventricular remodelling and clinical outcomes after Wharton's jelly multipotent stem cells transcoronary administration in a pilot cohort of CIRCULATE-AMI Trial (NCT03404063)

Introduction

CIRCULATE-Acute Myocardial Infarction Trial (NCT03404063) is a double-blind controlled trial (RCT) that is randomizing consecutive patients with their first, large AMI (LVEF ≤45% and/or cMRI -infarct size ≥10% of LV) successfully treated by infarct-related artery (IRA) primary percutaneous coronary intervention reperfusion (TIMI ≥2) to transcoronary administration of Wharton Jelly Multipotent Stem Cells (WJMSCs) vs. placebo (2:1), preceded by evaluation of safety, WJMSCs myocardial uptake, and echocardiographic, cMRI and SPECT left ventricular remodelling and hemodynamic changes in pilot study cohort (PSC).

Purpose

To evaluate LV remodelling and hemodynamic features following WJMSCs transplantation in CIRCULATE-AMI PSC.

Methods

Ten consecutive patients (age 32–65 years) were administered 30 000 000 WJMSCs via the infarct-related artery at ≈5–7 days after AMI using transradial approach and a coronary-non-occlusive catheter dedicated to cell delivery. Within 3 years of follow up SPECT was performed at baseline and 1 year, echo and cMRI were performed at baseline, 1 year and 3 years.

Results

3-year observation (cMRI) shows a significant decrease of median left ventricular mass (LVM) between WJMSCs administration and 1 year 140 g (IQR 128–150) vs. 97 g (95–128), that is sustained at 3 years 93 g (80–119), p<0,001. There were no significant changes of left ventriular end-diastolic volume (LVEDV) in all diagnostic methods: SPECT baseline vs. 1 year (157.1±27.1 ml vs. 174±24 ml); cMRI baseline vs. 1 year vs. 3 years (171.6±17.7 ml vs. 198.2±23.4 ml vs. 181.9±17.6 ml) and Echo (137±13.3 ml vs. 135±2.9 ml vs. 148±21.8 ml), p value >0,05 for all. Furthermore, there was a significant increase in stroke volume measured by SPECT baseline vs. 1 year (53.3±7.6 ml vs. 68.2±5.2ml); cMRI baseline vs. 1 year vs. 3 years (72.7±5.2 ml vs. 96.9±8.1 ml vs. 93.2±7.8 ml) and Echo (64.3±2.9 ml vs. 68.8±4.1 ml vs. 81.9±7.1 ml), p<0,05 for all. By 3 years there was one non-index territory AMI. There were no other adverse events in the study cohort.

cMRI Left Ventricular Mass evolution

Conclusions

Long-term follow up in CIRCULATE-AMI PSC suggests that transcoronary administration of WJMSCs in a recent large AMI in humans might be associated with an inhibition of LV adverse remodelling and a significant hemodynamic improvement. Our currently running randomized double-blind controlled trial will verify LV remodelling evolution in WJMSCs-treated patients.

Acknowledgement/Funding

K/ZDS/00564 Jagiellonian University Medical College; STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland

P1471Multimodality imaging of left ventricular function and volumes in patients with acute and chronic myocardial injury - Novel insights

Introduction

The three main techniques to evaluate myocardial function and volumes: two-dimensional echocardiography (TTE), gated single photon emission computed tomography (SPECT) and cardiac magnetic resonance imaging (cMRI), have important differences in accessibility and practicality.

Purpose

We aimed to evaluate: TTE, SPECT and cMRI in the measurement of left ventricular ejection fraction (LVEF), left ventricular end-diastolic (LVEDV) and left ventricular end-systolic volumes (LVESV) in patients with acute and chronic myocardial ischemic injury.

Methods

Consecutive patients with first large acute myocardial infarction (AMI) [LVEF ≤45% and/or cMRI infarct size ≥10% of left ventricle, 2–5 days after pPCI, n=10] and patients with chronic ischemic heart failure (CIHF) [LVEF ≤45% by SPECT, NYHA class II or III, n=10] were enrolled. Multimodality imaging using the study techniques was performed within 36 hours.

Results

LVEF measured with TTE, SPECT and cMRI did not differ between both groups (AMI: 41±2.5%, 37.9±2.7%, 41±2.7%; p=0.07, CHF: 29.6±3.2%, 29.7±3.0%, 32.9±4.9%; p=0.42). LVEDV and LVESV evaluated by SPECT were +33.6%, +38.2% higher in the AMI group and +40.7%, 40.4% higher in the CIHF group compared with TTE (p<0.001). When measured with cMRI they were +52.1%, +50.5%, +31.5%, +25.5% higher (AMI, CIHF group, respectively), compared with TTE (p<0.001).

There was a strong positive correlation between LVEF derived from TTE and SPECT (r=0.81, AMI; r=0.92, CIHF), TTE and cMRI (r=0.89, AMI; r=0.75, CIHF), SPECT and cMRI (r=0.88, AMI; r=0.76, CIHF; all p<0.01). As well as for LVEDV (r=0.79, 0.88; 0.90, 0.85; 0.76, 0.87; all p<0.05) and LVESV measurements (r=0.90, 0.91; 0.94, 0.89; 0.85, 0.85, all p<0.05).

Figure 1

Conclusions

There is a strong correlations between TTE, SPECT, and cMRI in the assessment of left ventricular function in patients with AMI or CIHF. However, TTE appears to significantly underestimate left ventricular volumes in relation to SPECT and cMRI.

P1800The benefit of atrial septal defect closure in patients with borderline shunt

Objective

Closure of atrial septal defect in patients with borderline shunt is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in the patients with the borderline shunt.

Methods

215 pts (126 F,89 M) with a mean age of 31.9±18.2 (16–58) years with a small ASD who underwent transcatheter closure were analyzed. All patients had an isolated secundum ASD with pulmonary to systemic blood flow Qp:Qs ratio≤1.5, mean 1.2±0.6 (1.1–1.5).

A symptom-limited treadmill exercise test with respiratory gas exchange analysis, transthoracic color Doppler echocardiographic study and Quality of life (QoL) (using the SF36 questionnaire (SF36q)) were repeated in all pts before and 36 months after the procedure.

Results

The device was successfully implanted in all pts (procedure time 19.1±5.2 (8–38) minutes, fluoroscopy time 8.1±4.4 (6–13) minutes). There were no major complications. The defect echo diameter was 7.7±3.9 (5 - 15) mm. The diameter of the implanted devices ranged from 6 to 18 mm.

After 36 months of ASD closure, all the pts showed a significant improvement of exercise capacity. 7 QoL parameters (except mental health) improved at 36 months of follow-up compared with baseline. The mean SF36q scale increased in 168 (78.1%) pts of mean 40.2±20.1 (9–72). The right ventricular dimension decreased in 173 pts (80.4%) (Table 1).

Table 1 Parameter Before ASD closure 36 months after ASD closure p value Time of exercise (min) 12.1±5.2 18.6±4.3 <0.001 VO2 peak (ml/kg/min) 10.2±4.7 14.8±4.2 <0.001 SF36q scale 0–100 37.3±22.3 79±29.5 <0.001 Right atrial area (cm2) 20.1±1.7 14.7±1.5 <0.001 Right ventricular area (cm2) 18.1±1.4 12.2±1.5 <0.001

Conclusions

ASD closure in patients with borderline shunt resulted in a significant and long-term clinical and hemodynamic improvement after percutaneous treatment.